Cash Advance Application

Business Information

 Agent:
Legal Corporate Name: DBA:
Physical Address:           City:   State: Zip:
Business Telephone: ()-ext. Fax: () - Fed Tax ID:
Contact Person:      Email Address: Website:
Date Business Started: Length of Ownership: Years at Location: # of Locations:
Ownership
Owner Name #1: Home Ph: ()- Cell Ph: ()-
Home Address:     City: State: Zip:
Date of Birth: SSN: D/Lic #: State: % Own: Title:
Owner Name #2: Home Ph: () - Cell Ph: () -
Home Address:     City: State: Zip:
Date of Birth: SSN: D/Lic # State: % Own: Title:
Bank Information
Name of Bank: Address: Contact: Phone: ()- ext.
Landlord
Landlord Name:   Contact: Cell #: () Work #: () Fax #: ()
Trade Suppliers
Business Name: Contact: Phone #: () -
Business Name: Contact: Phone #: () -
Business Name: Contact: Phone #: () -
Business Profile
Ownership:

Sole Proprietorship
Corporation
Partnership
LLC
LLP
PC/PA
Not for Profit

Merchant Type:

Retail
Restaurant
Lodging
Service
Internet
Home Based
Automotive
Other

Cards Accepted:

Visa
MasterCard
AMEX
Discover
Debit
LBT

Credit Card Processing:

Card Swipe  %
Manual Key  %
Telephone    %
Mail Order     %
Internet        %

*Total must equal 100%

Monthly Amounts:

Total Sales                
Credit Card Process  
Rent expense            
Goods purchased       
Non-owner payroll     
Owner draw/salary  

Digital Signature

Applicant authorizes 1st Merchant Funding, its assigns, agents, banks or financial institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant. Applicant, by signing below, represents that all the information is complete and accurate.
Name:

Date: